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COM PENDIUM 



THE PHYSICAL DIAGNOSIS OF 



Diseases affecting the Lungs and Hearti 



; j 



By Austin Flint, M.D, 



Fourth Edition, 




New York : 

WILLIAM WOOD & COMPANY. 



1869. 






Entered according to Act of Congress, in the year 1868, by 

AUSTIN FLINT, M.D,, 

In the Clerk's Office of the District Court of the United States for the 

Southern District of New York. 



The New York Printing Company, 

8 1, 83, and S5 Centre Street ^ 

New York. 



PEEFACE 



h 



This little compendium was prepared several 
years ago, by request of a medical friend who 
intended it for insertion in an annual Physician's 
Visiting Book. The latter publication was aban- 
doned, and the compendium was published by 
itself. It has been found convenient in aiding 
to memorize physical signs, by the private 
pupils of the writer, and by others, and it has 
been reprinted in compliance with a demand 
for this purpose. It is designed, not as a substi- 
tute for works treating of auscultation and per- 
cussion, but, on the contrary, to promote the 
study of treatises which consider fully these 
and the other methods of physical exploration, 
together with the diagnosis of diseases affecting 
the respiratory organs and the heart. 



COMPENDIUM 

OF 

PERCUSSION AND AUSCULTATION, 

AND OF 

THE PHYSICAL DIAG:N^0SIS OF DISEASES AFFECTING 

THE LUiS^GS AND HEART. 

By AUSTIN FLINT, M.D. 

SUMMARY OF PULMONARY SIGNS OBTAINED BY 
PERCUSSION AND AUSCULTATION, THEIR DIS- 
TINCTIVE CHARACTERS AND SIGNIFICANCE.* 

PERCUSSION. 

Normal Vesicular Resonance. — The reso- 
nance obtained by percussing the healthy chest, 
varying in intensity in different persons, the 
pitch low, the quality peculiar and distinguished 
as vesicular. The resonance greater, the vesic- 

* For a fuller exposition of the distinctive characters and 
significance of the signs obtained by percussion and auscul- 
tation, vide the work of the writer entitled "^ Practical 
Treatise on the Physical Exploration of the Chest and the Diag- 
nosis of Diseases affecting the Respiratory Organs^ — 2d Edition, 
Vide, also, article in Am. Jour, of Med. Sciences, No. for 
April, 1862. 



ular quality more marked, and the pitch lower 
at the left than at the right summit of the chest 
in front. 

ABNORMAL MODIFICATIONS OF THE NORMAL 
VESICULAR RESONANCE. 

Diminished Resonance, or Dulness. — The 

resonance less and the pitch higher than the 
normal vesicular resonance. Denotes that the 
proportion of solids, or of liquid, over air within 
the chest, is greater than in health. Incident to 
partial solidification of lung in pneumonia, 
tuberculosis, &c., to pulmonary congestion, to 
moderate or small pleuritic effusion, to moderate 
oedema of lung, and to collapsed lobules. 

Absence of Resonance, or Flatness. — Eeso- 

nance wanting, i.e. complete abolition of sono- 
rousness. Denotes absence of air within the 
part of the chest percussed. Incident to com- 
plete solidification of lung, to liquid effusion, to 
great oedema of lung, and to tumor within the 
chest. 



Tympanitic Resonance. — A resonance de- 
void of the vesicular quality which distinguishes 
the normal vesicular resonance. The intensity of 
the resonance either greater or less than in health. 
It is invariably higher in pitch than the normal 
vesicular resonance. It proceeds from air in 
the pleural sac, or in pulmonary cavities, or in 
the large bronchial tubes sometimes on percus- 
sion over the upper lobes ; and it may be con- 
ducted from the stomach or colon by solidified 
lung. Incident to pneumo-thorax, to some cases 
of solidified lung, and to tuberculous exca- 
vations. 

Amphoric Resonance. — A variety of tym- 
panitic resonance, characterized by a musical 
intonation like that produced by blowing over 
the open mouth of a phial. Incident to some 
cases of pneumo-thorax, and to tuberculous 
cavities ; occasionally produced over solidified 
lung. 

Cracked Metal Resonance. — Another vari- 
ety of tympanitic resonance. Incident to tuber- 



8 

culous cavities, but occasioriallj produced over 
solidified lung, and sometimes in the infra-cla- 
vicular region of young subjects in health. 

Vesiculo-Tympanitie or Exaggerated 
Resonance. — The resonance of greater intensity 
than in health ; the character not vesicular as in 
health, nor purely tympanitic, but presenting 
the tympanitic and the vesicular quality mixed 
in variable proportions; the pitch raised in 
proportion as the tympanitic quality predom- 
inates. Incident especially to dilatation of the 
air-cells in emphysema, to lung containing air 
and floating on liquid within the chest, and to a 
healthy lobe when its fellow is solidified. 

AUSCULTATION. 

1. Auscultation of the Sespiration. 

Normal Vesicular Murmur. — The respira- 
tory sound obtained by auscultation in health. 
The murmur produced by the act of inspiration 
is more or less intense, low in pitch, and has a 
peculiar quality distinguished as vesicular. The 
murmur with expiration is not always present ; 



9 

when present it is much shorter than the in- 
spiratory murmur, less intense, stiUJower in 
pitch, and it has a simple blowing quality. 
These characters vary considerably, within the 
limits of health, in different persons. The mur- 
mur with inspiration is more intense, more 
vesicular, and lower in pitch at the left than at 
the right summit of the chest in front. The ex- 
piratory sound is not infrequently prolonged at 
the right summit, especially in females, and it 
may be more or less high in pitch. 

ABNORMAL MODIFICATIONS OF THE NORMAL 
VESICULAR MURMUR. 

Exaggerated Vesicular . Murmur. — In- 
creased intensity of the murmur on the healthy 
side when the respiratory function on^ the op- 
posite side is compromised by disease, as in cases 
of pleurisy with large effusion, pneumonia, etc. 
The characters of the murmur, irrespective of 
intensity, not essentially changed; called, also, 
supplementary ^nd2nceril6 respiration. 

Diminished Vesicular Murmur. — The mur- 



10 

mur weakened, but its distinctive characters 
otherwise not materially affected. Incident to 
dilatation of the air cells or emphysema, and 
to cases of bronchitis. 

Suppressed Respiratory Murmur. — 

Absence of any sound with the respiratory acts. 
Incident to large pleuritic effusion, to some cases 
of solidification of lung, and to tumor within the 
chest. 

Bronchial or Tubular Respiration — An 

inspiratory sound devoid of the vesicular quali- 
ty, and, in place thereof, a quality distinguished 
as tubular, the pitch higher than the inspiratory 
sound in the normal vesicular murmur, and the 
intensity variable ; an expiratory sound as long 
as, or longer than, the sound of inspiration, the 
pitch higher than that of the inspiratory sound, 
the intensity usually greater, and the quality, 
like that of the inspiratory sound, tubular. 
These characters of the bronchial, as compared 
with the normal vesicular respiration, are iden- 
tical with the characters of the normal laryngeal 



11 

and traclieal respiration. The bronchial respira- 
tion denotes complete or considerable solidifica- 
tion of lung, from morbid deposit, as in pneumo- 
nia, tuberculosis, etc., or from condensation, as 
when compressed by liquid effusion, and in cases 
of collapse. 

Broneho-Vesieular Respiration. — The ve- 
sicular quality of the inspiratory sound more or 
less diminished, but not entirely wanting as it is 
in bronchial respiration ; the quality approach- 
ing the tubular in proportion as the vesicular 
quality is diminished, and the pitch raised in 
proportion as the tubular predominates over the 
vesicular quality. The expiratory sound more 
or less prolonged, its intensity increased, its 
quality tubular, and its pitch raised in propor- 
tion as the inspiratory sound has less of the vesi- 
cular and more of the tubular quality. This 
abnormal modification is distinguished, as the 
name implies, by the mixture, in various pro- 
portions, of the characters of the bronchial and 
the normal vesicular respiration. The presence 



12 



of any of the vesicular quality in inspiration 
shows that the respiration is not bronchial, but 
broncho-vesicular. The characters may approx- 
imate, on the one hand, to the bronchial, or, on 
the other hand, to the normal vesicular respira- 
tion ; and between these extremes there is every 
degree of gradation. The sign denotes partial 
solidification of lung. In proportion as the solid- 
ification approximates to an amount sufficient 
to give rise to the bronchial respiration, the 
characters of the broncho- vesicular will approx- 
imate to the bronchial. On the other hand, the 
characters will approximate to the normal vesi- 
cular when the solidification is slight. By means 
of this sign, therefore, not only the existence of 
solidification, but its amount, may be determined. 
This has been called mcde^ roitgh^ and harsh 
respiration. Its intensity may be greater or less 
than that of health}^ respirations. 

Cavernous Respiration. — An inspiratory 
sound, devoid of vesicular quality, not tubular 
but blowing, and low in pitch ; an expiratory 



13 

sound, lower in pitch than the inspiratory. 
(Contrast these characters with those of bron- 
chial respiration.) Heard within a circum- 
scribed space, and not infrequently surrounded 
by bronchial respiration. Denotes passage of air 
into and from a cavity with flaccid walls. 

Amphoric Respiration. — A variety of cav- 
ernous respiration characterized by a musical in- 
tonation resembling the sound produced by blow- 
ing over the mouth of an empty phial. Denotes 
generally pneumo-thorax and perforation of lung, 
but sometimes due to a tuberculous cavity with 
rigid walls. 

ADVENTITIOUS SOUNDS, OR RALES, PRODUCED 
WITHIN THE AIR-CELLS, BRONCHIAL TUBES, 
PULMONARY CAVITIES, AND THE PLEURAL SAC. 

Crepitant Rale. — A dry^ very fine, crack- 
ling sound, heard only with the act of inspira- 
tion, and, if heard in only a part of this act, 
always confined to the latter part. Almost 
pathognomonic of pneumonia. Heard especial- 
ly in the first stage of that disease. Occasion- 



14 

ally incident to CBdema of the lungs and to 
haemoptysis. Produced within the air vesicles 
and bronchioles. 

Sub-Crepitant Rale. — A moist^ fine, bub- 
bling sound, conveying the idea of small bub- 
bles, heard with either inspiration or expiration, 
or with both acts, not infrequently intermingled 
with the crepitant rale. Produced within the 
bronchial tubes of small size. Incident to capil- 
lary bronchitis, oedema of lungs, hasmoptysis, 
and heard in the resolving stage of pneumonia. 

Moist Bronchial or Mucous Rales. — 

Bubbling sounds due to the presence of mucus 
or other liquid in the bronchial tubes of larger 
size than those in which the sub-crepitant rale is 
produced. They are called coarse or Jine^ ac- 
cording to the size of the tubes in which they 
are produced. Incident to bronchitis and other 
affections giving rise to the presence of liquid in 
the tubes. 

Sibilant and Sonorous Rales. — Dry sounds, 
frequently musical, produced by narrowing of 



15 

the calibre of the bronchial tubes. If high in 
pitch, they are sibilant or whistling, and gen- 
erally produced within small-sized tubes. If 
low, they are sonorous or snoring, and produced 
within large-sized tubes. Incident to asthma 
especially ; also to bronchitis. 

Cavernous Rale or Gurgling. — A moist 
sound produced hy the bubbling and agitation 
of liquid within a cavity. The name gurgling 
is descriptive of the character of the sound. Its 
situation is circumscribed. 

Pleural Friction Sound. — A sound of gra- 
zing, rubbing, or grating, due to the movements, 
in opposite directions, of the costal and pulmo- 
nary pleural surfaces with inspiration and expi- 
ration. The sound is more or less intense, dry, 
appears to be near the ear, heard usually with 
both acts of respiration, and conveys to the 
mind the idea of friction of roughened surfaces. 
The sound is generally not continuous, but in- 
terrupted ; that is, there is a series of friction 
sounds with either inspiration or expiration, or in 



16 

both acts. Denotes that the pleural surfaces are 
roughened by lymph or other deposit. Incident 
to pleurisy, especially after the absorption of 
liquid effusion. 

Metallic Tinkling. — A series of tinkling 
sounds, with expiration, or inspiration, or both 
acts ; also produced by speaking and coughing. 
Denotes air and liquid within a space of con- 
siderable size. Incident chiefly to pneumo-hy- 
drothorax; sometimes produced within a large 
tuberculous excavation. 

2. AusGidtation of the Voice. 

Normal Vocal Resonance. — A diffused, 
distant resounding of the voice in health, accom- 
panied with more or less vibration of the walls 
of the chest, or fremitus. Yaries much in degree 
in different healthy persons. Always louder on 
the ris'ht than on the left side of the chest. 



'iD^ 



Normal Bronchial Whisper. — A blowing 
sound heard with whispered words, at the upper 
part of the- chest, in front and behind, and more 



17 

marked in proportion as the ear approaclies the 
site of the primary bronchi. The sound varies 
considerably in intensity in different healthy 
persons. It is louder at the right than at the 
left summit of the chest ; but the pitch is some- 
what higher on the left side. It is comparative- 
ly feeble, and often wanting, over the middle and 
the lower third of the chest. Its characters 
correspond to those of the expiratory sound in 
forced breathing. 

ABNORMAL MODIFICATIONS OF VOCAL RESO- 
NANCE AND BRONCHIAL WHISPER, 

Bronchophony. — The voice concentrated, 
near the ear, raised in pitch, and more or less 
intense. Denotes solidification of lung, either 
complete or considerable. 

Whispering Bronchophony. — A high- 
pitched, tubular sound, with whispered words, 
near the ear, and more or less intense. The 
signification the same. This and the preceding 

sign are correlative with bronchial respiration. 

2 



18 

Exaggerated Vocal Resonance. — The re- 
sonance of the voice diffused and distant as in 
health, but its intensity abnormally more or less 
increased. Denotes a degree of solidification in- 
sufficient for the production of bronchophon3^ 

Exaggerated Bronchial Whisper. — A 

sound, with whispered words, abnormally intense, 
but not so intense, and not so acute nor so near 
the ear, as in whispering bronchophony. Has 
the same significance as exaggerated vocal reso- 
nance. This and the preceding sign are correla- 
tive with broncho- vesicular respiration. 

Pectoriloquy. — Transmission of the speech, 
i.e. articulate words, to the ear. It may be either 
bronchophonic or cavernous. 

Cavernous Whisper. — A sound, with whis- 
pered words, notably low in pitch, and blowing 
or hollow in quality, as compared with whisper- 
ing bronchophony. Denotes a cavity. 

Amphoric Voice or Echo. — A musical 



19 

sound like that produced by blowing into an 
empty bottle. It may accompany or follow the 
loud voice or whispered words. Incident espe- 
cially to pneumo-thorax, but also occasionally to 
tuberculous cavities. 

^gophony. — A modification of bronchopho- 
ny, consisting in tremulousness of the sound, 
causing it to resemble the bleating of a goat. 
Occasionally heard in pleurisy and pneumonia. 

Diminished and Suppressed Vocal Reso- 
nance.^-The resonance either more or less ab- 
normally lessened or wanting. Incident espe- 
cially to pleuritic effusion, and to pneumo- 
thorax. 

PHYSICAL SIGNS INVOLVED IN THE DIAGNOSIS 
OF PULMONARY AFFECTIONS. 

Bronchitis Affecting the Large Tubes. — 

Normal vesicular resonance on percussion. 
Sibilant or sonorous rales, or both, in early 
stage, on both sides of the chest ; feebleness of 
respiratory murmur. Temporary suppression 



20 

of murmur over portions of chest. Subse- 
quently mucous rales on both sides of the chest. 
The rales very variable, not always present, 
coming and going, and changing their situation. 
The vocal resonance normal. 

Bronchitis Affecting the Small Tubes. — 

ITormal vesicular resonance on percussion. Sub- 
crepitant rales on both sides of the chest. Weak- 
ened or suppressed respiratory murmur. Normal 
vocal resonance. 

Asthma. — Eesonance on percussion either 
normal or increased. Sibilant and sonorous rales 
diffused over the chest, often loud enough to be 
heard at a distance. Normal vocal resonance. 

Pulmonary Emphysema. — Yesiculo-tym- 
panitic resonance on percussion over both upper 
lobes, generally most marked at the left summit 
in front. Eespiratory murmur feeble or sup- 
pressed. The inspiratory sound shortened (de- 
ferred). The expiratory sound frequently pro- 
longed, but not tubular nor raised in pitch. 



21 . 

Sibilant and sonorous rales frequently present. 
The superior and middle thirds of chest, in front, 
bulging, and the lower part contracted. Marked 
and characteristic deformity of chest in some 
cases. Vocal resonance not affected. 

Pleurisy Tvith Effusion and Empyema. 

— If the pleural sac be filled either with lympho- 
serous liquid or pus, universal flatness on per- 
cussion over the affected side. Generally ab- 
sence of respiratory sound except over the com- 
pressed lung at the summit, and, here, bronchial 
respiration. Enlarged dimensions of the affected 
side, if the liquid be sufficient to dilate the chest, 
as shown by mensuration or the eye. Deficient 
respiratory movements or immobility. The in- 
tercostal spaces on a level with the ribs, and 
sometimes bulging. Dislocation of the heart, its 
site being shown by the impulse or sounds. 
Normal vocal resonance diminished or suppress- 
ed. Vocal fremitus wanting. Exceptionally, 
the bronchial respiration emanating from the 
compressed lung is more or less diffused, and 



22 

it may extend over the whole of the affected 
side. 

If the chest be partially filled, flatness or dul- 
ness on percussion from the base of chest, 
extending upward to a horizontal line, denoting 
the level of the liquid, when the patient is sitting 
or standing. Eesonance extending below this 
line, in front, in some cases, when the patient 
lies on the back, owing to a change of level of 
the liquid. Vesiculo- tympanitic resonance fre- 
quently over the lung above the level of the 
liquid. Diminution or absence of respiratory 
sound below the level of the liquid. Above 
the liquid the respiration broncho- vesicular, and 
sometimes bronchial near the liquid. Vocal 
resonance and fremitus diminished or wanting 
below the level of the liquid, and both may be 
exaggerated above the liquid. Bronchophony or 
segophony sometimes near the level of the liquid. 
Diminution of intercostal depressions may be 
apparent when the chest is partially filled. Ex- 
aggerated respiration on the healthy side when 
the chest is partially, and still more when it is 



23 

completely, filled. Pleural friction sound some- 
times prior to and with liquid effusion ; fre- 
quently during and after absorption of liquid. 
A characteristic contraction of the chest on the 
affected side follows chronic pleurisy with con- 
siderable effusion. 

Pneumo-Hydrothorax. — Tympanitic reso- 
nance extending either over the whole of the 
affected side, or a certain distance from the 
summit, when the patient is sitting or standing, 
with dulness or flatness extending below to the 
base. The relation of dulness or flatness and 
tympanitic resonance changing when the patient 
lies on the back, owing to change of level of the 
liquid. The tympanitic resonance sometimes 
amphoric. Amphoric respiration and voice 
frequently present, also metallic tinkling. 
Splashing sound on succussion, and this sound 
frequently amphoric. Suppression of respiratory 
murmur and of vocal resonance. Dilatation of 
the affected side in certain cases, with deficient 
motion, and abolition of intercostal depres- 



24 ^- . . 

sions. The heart removed from its normal 
situation. 

Hydrothorax or Dropsical Pleural Effu- 
sion. — The signs denoting presence of liquid in 
both pleural sacs ; the amount of liquid often 
greater in one side. The evidence of liquid afford- 
ed by its change of level with the change of 
position of the patient is almost alwaj^s available. 

Pneumonia. — In first stage, slight or mode- 
rate dulness over the affected lobe, and frequent- 
ly, but not invariably, the crepitant rale, the 
latter being almost pathognomonic. In second 
stage, marked dulness, or flatness, over a space 
corresponding to that occupied by the affected 
lobe or lobes. Vesiculo-tympanitic resonance 
over the upper lobe if the lower lobe be alone 
affected, and over the lower lobe if the upper be 
alone affected. The relation of resonance and 
dulness or flatness not changing with change of 
the position of the patient. Bronchial respiration 
generally present in this stage, and usually 
bronchophony with the loud voice, together 



25 

with whispering bronchophony. Persistence of 
crepitant rale in some cases. In stage of puru- 
lent infiltration, dulness or flatness continuing, 
with mucous rales. During resolution, progres- 
sive diminution of dulness, the bronchial respira- 
tion giving place to the broncho-vesicular, 
the latter approximating to, and at length 
eventuating in, the normal vesicular murmur. 
During this period, sometimes a return of the 
crepitant rale, and frequently a sub-crepitant 
rale. Bronchophony, during resolution, giving 
place to exaggerated resonance, and the latter 
diminishing and ending in the normal vocal 
resonance. 

Collapse of Pulmonary Lobules in Con- 
nection -w^ith Bronchitis in Children, or 
Lobular Pneumonia. — Dulness on percussion, 
greater or less, and more or less diffused, often- 
est on the posterior surface of chest on both 
sides, with either diminution of respiratory mur- 
mur or feeble bronchial respiration. Mucous or 
subcrepitant rales on both sides. 



26 

Pulmonary (Edema. — Dulness or flatness 
on percussion more or less diffused over the 
posterior surface of the chest, on both sides. 
Subcrepitant, sometimes intermingled with 
crepitant, rale. Absence of respiratory murmur, 
or feeble broncho-vesicular respiration. No 
change as regards the situation of, or space 
over which the dulness extends, with change 
of position of the patient. 

Pulmonary Gangrene. — Dulness or flatness 
on percussion over a space more or less circum- 
scribed, oftenest over the scapula. Absence of 
respiration within this area, or bronchial respira- 
tion, together with, in some cases, either bron- 
chophony or increased vocal resonance. Mucous 
or subcrepitant rales within the area of dulness 
or flatness and its neighborhood. Cavernous 
signs may be present after the sloughing away 
of a circumscribed portion of lung. The signs 
of pneumo-hydrothorax become developed if 
perforation of the lung take place. 

Pulmonary Apoplexy.— Dulness or flatness 



27 

on percussion within a circumscribed space or in 
circumscribed spaces. Absence of respiratory- 
murmur within the limits of the extravasations, 
or bronchial respiration. Mucous or subcrepi- 
tant rales. 

Carcinoma of Lung. — The signs of solidifi- 
cation, greater or less in degree, and more or 
less diffused. Sometimes contraction of one 
side and lessened respiratory movement. 

Pulmonary Tuberculosis. — If the deposit 
of tubercle be abundant, dulness on percussion 
at the summit of the chest on one side, greater 
or less, with bronchial or broncho-vesicular 
respiration, bronchophony or exaggerated vocal 
resonance, whispering bronchophony or exag- 
gerated bronchial whisper, and increased vocal 
fremitus. Frequently, depression below the 
clavicle, and diminished respiratory movement 
in that situation. The signs of solidification 
may show a less amount of deposit at the other 
summit. Exceptionally, the signs may denote 
a tuberculous deposit at the base. A cavity, or 



28 

cavities, may be shown by cavernous respiration, 
amphoric respiration and voice, cracked metal 
or amphoric resonance on percussion, and 
gurgling. 

If the deposit be small or moderate, slight 
dulnesson percussion at the summit on one side, 
or sometimes a vesiculo-tympanitic resonance 
due to emphysematous lobuies in the neighbor- 
hood of the deposit, with diminished respiratory 
murmur, or a broncho-vesicular respiration, 
increase of vocal resonance, and exaggerated 
bronchial whisper. 

Accessory signs important in determining the 
existence of a deposit of tubercle, when the 
amount is small or moderate, are, mucous or 
subcrepitant rales, limited to the summit on one 
side ; a friction-murmur, crumpling or crackling 
sounds, interrupted or jerking respiration, limit- 
ed in like manner ; also, abnormal transmission 
of the heart-sounds, and a subclavian bellows 
murmur. 

Diaphrag-matic Hernia.— Tympanitic reso- 



29 

nance on percussion not otherwise explicable, 
with suppression of respiratory murmur, and 
the presence of the characteristic intestinal 
sounds. 

PHYSICAL SIGNS INVOLVED IN THE DIAGNOSIS 
OF AFFECTION OF THE HEART. 

Aortic Obstructive Lesions. — An organic 
endocardial murmur accompanying and follow- 
ing the first sound of the heart (systolic) ; loud- 
est at, or limited to, the base of the organ ; 
generally propagated into the carotid arteries ; 
its maximum of intensity in the second inter- 
costal space on the right side near the sternum, 
provided the normal relation of the aorta to the 
chest walls be preserved; the aortic second 
sound of the heart, as heard in the situation just 
designated, weakened or lost, if the aortic valves 
be damaged. ^ 

* An aortic direct murmur may be inorganic or anaemic. 
This is to be inferred when the murmur is variable in its in- 
tensity, or intermittent, unaccompanied by weakening of the 
aortic second sound, the heart not enlarged, and murmurs 
heard in the large arteries and in the veins of the neck. 



30 

Aortic Regurgitant Lesions. — An endocar- 
dial murmur accompanying and following the 
second sound of the heart (diastolic) ; loudest just 
below the base of the heart on the left side of, or 
over, the sternum, propagated thence downward 
toward the ensiform cartilage. The aortic second 
sound weakened in proportion as the aortic 
valves are defective. This murmur is frequent- 
ly conjoined with the aortic direct murmur. 

Mitral Regurgitant Lesions. — An endocar- 
dial murmur accompanying and following the 
first sound of the heart (systolic) ; loudest at, or 
limited to, the apex of the organ ; extending 
more or less to the left of the apex laterally 
around the chest, and heard at the lower angle 
of the scapula ; not propagated into the carotids. 
The aortic second sound of the heart weakened 
in proportion to the amount of regurgitation, 
and the pulmonic second sound (heard in the 
left second intercostal space near the sternum) 
intensified in proportion to the amount of hy- 
pertrophy of the right ventricle induced by the 



81 

mitral lesions. A mitral murmur, beginning 
with the first sound of the heart, does not always 
denote mitral regurgitation. Such a murmur 
may be distinguished as a mitral systolic mur- 
mur, or an intra- ventricular murmur. 

Mitral Obstructive Lesions. — An endocar- 
dial murmur not connected with the second 
sound of the heart, but preceding the first sound 
(proe-systolic), and abruptly arrested at the oc- 
currence of the first sound ; the murmur limited 
to a circumscribed space around the apex of the 
organ; the character frequently peculiar, re- 
sembling the sound caused by throwing the lips 
or tongue into vibration with the breath ot 
expiration. The pulmonic second sound of the 
heart intensified, if the mitral lesions have led to 
hypertrophy of the right ventricle. This 
murmur is frequently associated with the mitral 
regurgitant. It does not denote mitral lesions, 
in all cases, when it is associated with aortic 
regurgitant lesions. 

Tricuspid Regurgitation.— An endocardial 



32 

murmur with the first sound of the heart 
(systolic), heard within a circumscribed area at 
the lower part of the sternum. Frequently, if 
not generally, associated with pulsation or un- 
dulation in the jugular veins. 

Lesions at Pulmonic Orifice. — An endo- 
cardial organic murmur with the first sound of 
the heart (systolic), at the base of the organ, in 
the left second intercostal space ; not propagated 
into the carotids."^ 

Endocarditis in cases of Articular Rheu- 
matism. — An endocardial murmur, loudest at 
the apex of the heart, i. e., a mitral systolic 
murmur, developed (i. e. not having existed 
previously) in connection with articular rheuma- 
tism. 

Pericarditis. — A pericardial friction murmur 

* A pulmonic direct murmur is frequently inorganic or 
anaemic. This is to be inferred when the circumstances are 
present which have been mentioned in connection with an 
inorganic aortic direct murmur. 



33 

(exocardial), distinguished from an endocardial 
murmur by the following points: Conveying 
the idea of rubbing or friction ; apparently su- 
perficial ; usually two sounds for each beat of 
the heart; varying in intensity and character 
during auscultation; its relation to the heart 
sounds not definite, or the rhythm irregular; 
not propagated much, if at all, beyond the limits 
of the heart, and frequently limited to the super- 
ficial cardiac space ; intensified notably by firm 
pressure with the stethoscope ; disappearing, in 
some cases, during the stage of pericardial eff\i- 
sion, and finally ceasing after pericardial adhe- 
sions have taken place. Generally associated 
with endocardial murmur or murmurs. 

The existence and amount of pericardial effu- 
sion are shown by increased dulness or by flatness 
in the pericardial region, within a triangular or 
pyriform space, corresponding to the size and 
figure of the distended pericardial sac; the base 
situated a little below the level of the apex of 
the heart, and the summit extending toward or 

quite to the sternal notch ; the praecordia some- 

3 



34 

times projecting, and the intercostal depressions 
pushed out ; the impulse of the heart lost, or, if 
appreciable, raised to the fourth or third inter- 
costal space; the heart-sounds weakened and 
distant ; the first sound short and val^irular like 
the second sound. 

In chronic pericarditis, with large effusion, the 
dilatation of the pericardial sac is shown by dul- 
ness or flatness extending laterally, more or less, 
from the prsecordia, on both sides of the chest, 
together with the other signs just mentioned. 

Hypertrophy of Heart or Enlargement 
with Predominant Hypertrophy. — The apex- 
beat lowered from the fifth intercostal space to the 
sixth, seventh, or eighth, according to the amount 
of enlargement, and often removed to the left 
of its normal situation one, two, or three inches. 
The apex-beat in some cases notably strong, but 
in other cases weak, in consequence of the change 
in form of the heart. Impulses in the intercostal 
spaces above the apex-beat, and these notably 
strong. Heaving movement of the whole of the 



35 

praBCordia, with more or less power. Enlarge- 
ment of the superficial cardiac space, as shown 
by percussion, and the degree of dulness notably 
greater than in health. The left margin of the 
heart extending without the left nipple, as deter- 
minable by deep percussion. The intensity, 
length, and booming quality of the first sound 
of the heart, over the apex or body of the organ, 
increased. 

If the hypertrophic enlargement exist without 
valvular lesions (which is rare), absence of or- 
ganic murmur. 

Enlargement of the Heart with Predo- 
minant Dilatation. — The fact of enlargement 
and its degree determined by the same signs as 
when the enlargement is due to predominant 
hypertrophy. The predominance of dilatation 
shown by feebleness of the apex-beat and of 
other impulses ; by absence of heaving of the prse- 
cordia, and by the diminished intensity of the 
first sound, and its being short and valvular like 
the second sound. Absence of organic murmur 
if valvular lesions do not coexist, which is rare. 



86 

Patty Degeneration of the Heart. — Per- 
sisting feebleness of the apex-beat or other im- 
pulses; weakness of the first sound, with short- 
ening, and valvular quality like the second sound, 
these signs not being referable to dilatation. 

Functional Disorder of Heart. — Absence 
of organic murmur and of enlargement, and the 
heart-sounds normal in all respects save inten- 
sity.*^ 

* For a fuller exposition of the physical signs, etc. , of 
affections of the heart, mde a practical treatise on the 
diagnosis, pathology, and treatment of these affections, by 
the writer. 



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